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UPJ obstruction and lower pole crossing vessels: further experince with the laparoscopic vascular hitch

Villemagne Thierry¹, Fourcade Laurent³, Szwarc Caroline¹, Camby Caroline², Lardy Hubert¹, Leclair Marc-David²

¹CHRU Tours, Tours, France, ²CHU Nantes, Nantes, France, ³CHU Limoges, Limoges, France

 

Abstract 

Purpose: The transposition of lower pole crossing vessels has been reported as an alternative technique to dismembered pyeloplasty for the treatment of ureterovascular ureteropelvic junction (UPJ) obstruction. We report a multi-institutional experience with laparoscopic transposition in children with intermediate follow-up.
Patients and Methods: Retrospective analysis of 55 consecutive children treated by laparoscopic transposition of crossing vessels at 3 universitary institutions. Candidate patients were selected on the basis of clinical history, renal ultrasonography, preoperative MAG-3 renal scan, and angio-CTscan or magnetic resonnance angiography. Selection criteria included presence of lower pole crossing vessels with moderate hydronephrosis, poor renal drainage, and intra-operative normal ureter with UPJ peristalsis. All children were followed clinically with renal ultrasonography and postoperative MAG-3 renal scan. Success was defined by symptoms resolution with improvement in hydronephrosis and drainage.
Results: 55 children (33 boys, 22 girls) presenting with flank pain, hydronephrosis SFU grade 1 or 2, impaired drainage on MAG-3 and lower-pole crossing vessels at a mean age of 8.5 years (range 2.75-16) were selected. Operations were perfomed through transperitoneal laparoscopy (n=31) or robotic assisted (n=24). The mean operative time was 124 min. (60-280), and length of hospital stay was 3 days (1-17). With a mean follow-up of 31 months (11-84), outcome was successful in 50/55 patients (91%), with resolution of symptoms, improved hydronephrosis and better drainage on MAG-3. There were 2 failures in children presenting recurrent pain and worsened hydronephrosis during postoperative course, who initially required ureteral stent placement, and eventually underwent dismembered pyeloplasty. Three children have shown improvment of hydronephrosis and symptoms, but still show impaired drainage on MAG-3 renal scan and are closely followed-up. There was no significant difference between robotic and laparoscopic approaches regarding duration of surgery, analgesics requirements, and length of hospital stay.
Conclusions: At intermediate follow-up, the vascular hitch procedure, either robotic or laparoscopic, has been successful in treating a selected group of children with obstructive crossing vessels, and represents a safe and reliable alternative to standard dismembered pyeloplasty.